Modern approaches to minimally invasive ablative treatment of solid tumors involve the use of miniature instruments, and combined treatments like thermal ablation and systemic chemotherapy.
Cryosurgery is now recognized as an efficient, thermo-ablative, minimally invasive, method for a large number of solid tumors like prostate, lung, liver, kidney, to cite only a few. Cryosurgery affects tumor tissue viability in three different ways with immediate and delayed alterations: the freezing of tumor cells, and vasculature results in tumor kill through direct cell alterations, and indirect vascular occlusion.
Recently another mechanism of cell kill consecutive to cryothermal changes is apoptosis, a programmed, gene-regulated, cell death that has been shown predominant at the margins of a cryolesion, both at freezing and sub-freezing temperatures. The changes in microvasculature are now thought to be the main factors of tissue necrosis induced by freezing methods.
To achieve cryoablation, the entire tumor must be frozen to “kill” temperatures in the range of −40° C., the Freeze/Thaw, F/T, cycle must be repeated, and the kill temperature, out to the tumor margins, must be maintained for a few minutes, designated the, “hold time,” during cryosurgery. Despite a strict adherence to these standards, which are time consuming, certain tumors like prostate or metastatic liver cancer show a 20 to 40% post procedure recurrence. Whether the cause of this failure is disease-based or technique-related, it's recognized that cryosurgery needs the support of adjunctive therapy in the form of chemo- or radiotherapy to increase the rate of cell death at margins of the cryogenic lesion where the cell fate is known to be in balance for several days post treatment.
The pretreatment of a tumor with a pro-inflammatory protein like TNF-, based on the hypothesis that vascular-mediated injury is responsible for defining the edge of the cryolesion in micro vascular-perfused tissue, augments the cryoinjury that occurs at much higher temperatures, close to 0° C., due to a inflammatory pre-sensitization of the micro vasculature, Bo H. Chao, Xiaoming He and J. C. Bischof, Cryobiology 2004, 49, 10-27. Although this pretreatment seems better in terms of ablation completeness, it doesn't act directly on tumor cells and particularly on cells that may have escaped the margin of the cryolesion.
Hence there is a clear need for agents, neo-adjuvant or adjuvant to cryosurgery that could increase the cryosurgical kill as well as the tumor cell kill within and outside the frozen zone, while sparing the normal cells and tissue structures.
Systemic chemotherapy has long been used to enhance the kill effect of cryosurgery on experimental and human solid tumors, but results have been inconsistent. Probably because the combined treatments weren't based on sound protocols defining the drug, dosages, route of administration and timing of applications to cite only a few preeminent parameters. Since most common chemotherapeutic drugs initiate apoptosis in cancer cells, and given that a similar effect is observed with sub-freezing temperatures, the timely conjunction of each method has been sought for optimizing tumor cell death at tumor margin. A number of papers have shown that in vitro moderate freezing temperatures combined with low dose chemotherapy increased the rate of cell death for prostate and colo-rectal cancer cells. However, these findings weren't transferred to in vivo experiments. The issue with systemic chemotherapy is that the side effects cannot be prevented, tumor exposure to therapeutic doses is intermittent, and tumor penetration is unpredictable. Another drawback is that tumor cells still need to be frozen. Therefore, there is a risk of damage to neighboring normal tissue by excessive freezing. Moreover, the cytotoxic drug penetration into tumor may be difficult and imprecise upon initiation of cryo-induced microvascular impairments particularly if a precise timing between the drug administration and the cryo-application hasn't been respected. The drug properties are also critical and should be selected on the basis of their ability to act on the tumor cells as well as on the microvascular network constituents. There is a need for a more effective cryochemotherapy combination that would increase the tumor cell kill both in the frozen and unfrozen regions of the cryo-application and expose the cells and/or the microvascular bed to effective concentrations of drug for longer durations, while preventing systemic adverse effects.
Intra-tumor chemotherapy using different drugs and vectors or carriers of those drugs has been proposed to improve local delivery of chemotherapeutic agents and decrease their side effects. These new formulations, microspheres, liposomes, matrixes, etc., have the capability of slowly releasing the active component at therapeutic dose by diffusion through membrane and/or progressive degradation/lysis at body temperature. Such sustained release exposes cells to higher concentration of the cytotoxic drug for longer periods of time, prevent side effects and result in better outcome. The agents carriers are deposited locally or into the vascular bed of the tumor as the sole treatment and/or as a pre-adjuvant or adjuvant therapy to surgical excision, radiation therapy, 5-FU encapsulation and glioblastomas, as taught in U.S. Pat. No. 6,803,052, or microwave hyperthermia, as taught in U.S. Pat. No. 6,788,977 and U.S. Pat. No. 6,623,430. For the latter, moderate hyperthermia of the target organ, is triggering the release of the drug out of the thermo-sensitive, solid-matrix microsphere containing doxorubicins, Thermodox®. The company has initiated clinical studies for a combined treatment of liver malignant tumors that inject Thermodox® at periphery of a radiofrequency lesion, where tissue temperature is about +41° C. These treatments rely for their safety and efficacy on the precise, homogeneous deposition and known degradation rates of the carriers. Since these carriers cannot be imaged, there is no method to determine, in real time, the optimum delivery, in terms of spatial distribution and dose. Such assessments are based only on direct visualization, at open surgery, and on indirect measurement of tissue temperature.
Cryosurgery has been associated with curettage and topical chemotherapy with 5-FU for the treatment of actinic keratosis (AK) a pre-cancerous lesion that usually doesn't metastasize. One of the topical ointments Carac Cream contains 0.5% fluorouracil, with 0.35% incorporated into a patented porous microspheres, Microsponge®, composed of methyl methacrylate. However, the prescribed mode of application doesn't call for a specific geometric deposition of the cream, i.e. preferentially at lesion margins, or timing between cryoablation and chemoablation, and therefore isn't optimized to increase the cryo-kill at warmer temperatures and spare the neighboring normal skin.
Various drug mixtures and carriers containing cytotoxic agents have also been injected directly into the vascular bed of tumor through selective or supra-selective catheterization with adapted instruments. The combination of cytotoxic drug with agents of embolization is used to increase the cell death rate by submitting the tumor cells to elevated drug concentrations and ischemia consecutive to microvascular thrombosis. However, embolization techniques aren't easy, require specific and costly technologies and highly specialized departments, and the drug distribution isn't necessarily homogeneous.
A major drawback of the sustained-release drug carriers—delivery carriers (microspheres, liposomes, microcapsules, gel-foam particles, etc.) is that they aren't visible continuously, in real time using most of the available clinical imaging systems, i.e. ultrasound imaging, C-T radiography or fluoroscopy. As a consequence, the physician doesn't know whether the desired target site of deposition has been reached, nor whether the drug carriers are correctly distributed throughout the tumor or target tissues. To compensate for this drawback the mixtures or emulsions of insoluble contrast agents, like Ethiodol® carriers have been mixed with the drug solutions or carriers just prior to administration. However since the carrier and the contrast agent diffusion/distributions in tissues are different, the imaging of the contrast in the mixture doesn't give precise clue of the carrier location beyond a few minutes period. Another drawback is that a pinpoint placement of the depots into tumor requires a Perfect visibility of the delivery device throughout the procedure until the delivery tip reaches the targeted tumor region, particularly for deep-seated lesions.
Although a number of techniques are described to increase the echogenicity of delivery needles or catheters during various procedures, their characteristics aren't helpful for visualization in deep-seated lesions, where their effectiveness would be most desirable.
Another aspect of the drug release from biodegradable carriers can be effected in multiple ways: either spontaneous at core body temperature, or at-will triggered. Controlled release aims at: increasing effectiveness of drug by immediate and/or sustained release of large volume of drug, preventing complications, such as embolization, from carriers that have unwillingly moved to unwanted location, allowing for combined technologies that sensitize tumor cells by increasing their permeability to the drug.
Finally, since the cellular heterogeneity of malignant tumors is one of the major factors that explain tumor resistance to an initially effective single drug chemotherapy it would be an advantage to encapsulate a mixture of drugs that would overcome this chemo-resistance. Currently available sustained release systems encapsulate only a single drug.
There is a need for;                1. A minimally invasive, combined cryoablation method that would simultaneously expose the periphery of a tumor to effective concentrations of agent(s) for longer durations, while preventing systemic adverse effects, and sparing the patient's immune system.        2. Agent (s) or microcapsules of drugs, neo-adjuvant or adjuvant to minimal access computer-aided and image-guided cryosurgery, that would increase the safety and efficacy of the cryosurgical kill as well as the tumor cell kill while sparing the normal cells and tissue structures.        3. A new formulation of agent(s) or microcapsules or a combination of them that would allow for controlled and/or sustained release at targeted location(s) into tumor. Such formulation would simultaneously co-encapsulate contrast agent(s) and a cellular and/or vascular cytotoxic drug or drug(s) so that ultrasonic (US) imaging will monitor continuously the delivery device, the deposition and degradation of the agents' carriers particularly for deep-seated lesions.        4. A method that would optimize the selective tumor kill of the combination of the cryothermal ablation, of the imageable biodegradable drug(s) carriers, and of the imageable delivery device.        5. A Ultrasound-guided and minimal access combined procedure in which the drug-delivery and the drug-vector systems can be continuously imaged in real time so that the drug deposition site(s) as well as the drug release from the drug-vector degradation can be monitored over time at site of deposition.        